Provider Demographics
NPI:1801862552
Name:FAIRLEY, RICHARD JOHN (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JOHN
Last Name:FAIRLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 DELHI ST
Mailing Address - Street 2:STE 100
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-6320
Mailing Address - Country:US
Mailing Address - Phone:563-557-9111
Mailing Address - Fax:563-589-4046
Practice Address - Street 1:1515 DELHI ST
Practice Address - Street 2:STE 100
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-6320
Practice Address - Country:US
Practice Address - Phone:563-557-9111
Practice Address - Fax:563-589-4046
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA26557207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31478600Medicaid
IA0054981Medicaid
IA0054981Medicaid
IAA03665Medicare UPIN